• Communications

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• National Provider Identifier (NPI)

• NaviNet

• Private Fee-For-Service

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• Forms

• Resources for Patient Management

• Quality Management

• Prescription Drug Formulary & Prior Authorization

• IVR (Interactive Voice Response)

• Provider FAQ's

• Contact Information

Forms

The following forms are available:

• AIM Preauthorization/RQI Request Fax Form
• Connections Physician’s Referral Form — for eligible members
• Continuation of Care Form
• Direct Ship Injectables Request Form
• Emergency Room Review Form
• HIPAA Authorization Form — authorizes Independence Blue Cross to release member’s health information
• HIPAA Personal Representative Form — appoints another person as member’s personal representative
• Member Consent For Financial Responsibility Form
• Non-Formulary Exception Request Form
• Overpayment Refund Form
• PCP to Behavioral Health Provider Form
• Physician Claim Inquiry Form
• Populated Sample CMS-1500 (08/05) Claim Form with Instructions
• Prior Authorization Forms for prescription drugs
• Provider Change Form
• Surgical Team (Modifier -66) Documentation Form

Additional provider forms are available by calling the Provider Supply Line at 1-800-858-4728.